Adherence to Guidelines-Based Management of Non-Muscle Invasive Bladder Cancer Among Society of Urologic Oncology (SUO) Members - Justin T. Matulay
August 4, 2020
Justin T. Matulay, MD, Department of Urology, Levine Cancer Institute, Atrium Health
Ashish Kamat, MD, MBBS, President, International Bladder Cancer Group (IBCG), Professor of Urology & Cancer Research, MD Anderson Cancer Center, Houston, Texas
Variability in adherence to guidelines based management of nonmuscle invasive bladder cancer among Society of Urologic Oncology (SUO) members.
Variability in Adherence to Guidelines Based Management of Nonmuscle Invasive Bladder Cancer Among Society of Urologic Oncology (SUO) Members - Beyond the Abstract
Ashish Kamat: Welcome to UroToday's Bladder Cancer Center of Excellence. I'm Asish Kamat from MD Anderson Cancer Center. It's my distinct pleasure to welcome today, Justin Matulay, who just is finishing up a two-year fellowship with us here, and is positioned to become a real leader in the field of bladder cancer. Justin's going to be an Assistant Professor at the Levine Cancer entity of Atrium Health, and he has done a lot of exciting work while here at MD Anderson, and prior to that in residency as well. Today he's going to talk to us about the variability in guideline management and adherence, amongst members of the SUO. So with that, Justin, take it away.
Justin Matulay: All right. Thanks, Dr. Kamat. As Dr. Kamat said, I'll be finishing up my fellowship at MD Anderson and moving on to Levine Cancer Institute in Charlotte, North Carolina. This project was conceived during my first year at MD Anderson, and then we executed it throughout that first year and that second year. I think we have some very interesting results, and really have some interesting results that will give us a good jumping-off point for future projects.
The background problem that we were looking at was that, it's very well known that bladder cancer poses a pretty significant risk to the population, with about 81,000 new cases in 2020 alone. This represents roughly the fifth or sixth most common malignancy. Most of these diagnoses are going to be non-muscle invasive. And while that is good, because there are excellent survival outcomes for these nonmuscle-invasive cancers, it does pose a bit of an issue in terms of the longterm management of these patients, because there is significant morbidity associated with the management, and the treatment, and the diagnostic procedures; which also adds up to being a very costly cancer, and many sources have rated bladder cancer specifically as being the costliest cancer in the United States to manage.
So, we decided to see how experts in the field of urologic oncology are managing their bladder cancer patients, and specifically nonmuscle-invasive bladder cancer patients, in light of the AUA guidelines that have been in circulation now for about four years or so. They had some specific focus on the initial diagnosis and treatment of nonmuscle-invasive bladder cancer, the surveillance of bladder cancer, as well as imaging and biomarkers. So we decided to focus a survey around these three main topics.
We designed a 14 question web-based survey, and chose a web-based method because of ease of distribution, as well as ease of response for the individuals that we'd be reaching out to, and decided upon the SUO, or the Society of Urologic Oncology membership, due to their self identified interest in urologic oncology and decided that we would start with a group that had more experience managing bladder cancer, to see what their attitudes towards non-muscle invasive bladder cancer management were.
We had a total response rate of only about 16%, although this is consistent with many other web-based surveys, and shouldn't have too much of an impact in interpreting our results in comparison to other surveys. Of those respondents, we found that 84% identified themselves as urologic oncology trained specifically, meaning that they had attended a fellowship of either one or two years.
There was a nice distribution in the experience level of these urologists who responded, with about a third being in practice for less than five years, about a third over 15 years, and then the remaining third in the middle there. Most of the respondents, 71%, were in academic practice.
Overall adherence to the guidelines, which was determined by their response to the questionnaire, which gave specific case scenarios split by the different risk groups, the AUA risk groups, of low, intermediate, and high. The overall adherence to all questions was about 71%, which is pretty good. The adherence by risk group, however, and this is where we really focused in this paper was not as impressive, specifically among the low-risk category, where we only saw about 58% adherence to the guideline's statements.
Now among intermediate- and high-risk, the adherence was much higher, and these were adherence to things like the frequency of cystoscopy, the frequency of imaging, and/or the type of imaging that would be used, in addition to the use of biomarkers and urinary markers, like site urinary cytology.
In terms of just the raw univariate analysis, we didn't see too many differences among adherence based on fellowship training, or the number of years in practice. But we did see that those who identified themselves as urologic oncologists, tended to have a higher adherence, as well as those who were in an academic practice, over people who were hospital employed.
This slide right here, I think, is really the crux of our results of the paper. And that is that, you can see in blue highlighted here, the low-risk scenarios received the lowest adherence, and upper tract imaging, for instance, was overused in about two-thirds of cases. This is self-reported by these individuals. Most people are overusing routine surveillance, upper tract imaging. The use of urinary cytology is being used routinely with about 50% of urologists. Surveillance cystoscopies are being done at a rate greater than what is recommended by the guidelines, as well, in about 50%.
On a more in-depth dive into those low-risk patients, or those low-risk scenarios, in particular, we did find a couple of interesting trends, although the numbers here are low so this is really more just hypothesis-generating and less to be taken as direct evidence of any differences. However, the number of years in practice, for instance, interestingly did predict the use of cystoscopy. Those who were earlier in their career, or less than 10 years into practice, were more likely, 61% of them, adhered to the surveillance guidelines for cystoscopy, versus only 37% of those who had been in practice greater than 10 years. Likewise for uro-onc fellowship trained individuals, they were more likely to adhere to the guidelines, than those who had not been fellowship trained.
In conclusion, I really just pulled out the quick hits from this paper, but I think the bottom line is that intermediate- and high-risk were doing a pretty good job. I think the guidelines have convinced most people that to use what is set forth in the AUA guidelines is adequate for their practice. Most providers are willing to follow the recommended schedule of surveillance, for instance.
However, low-risk people still have not bought in. They are favoring the more intensive management strategies, doing cystoscopies at a much higher rate than what is currently recommended. This may be an opportunity to identify specific areas within nonmuscle-invasive bladder cancer management, specifically in that low-risk group, where we can improve our adherence to the guidelines, that might result in not only cost savings, but also a saving of the morbidity, and the invasiveness, and improve the patient experience surrounding bladder cancer management.
Finally, I just want to identify also, all of our collaborators. This was a very wide-ranging group of urologic oncologists who assisted with developing the survey and collecting the data. So we very much appreciate all of our collaborators in this effort.
Ashish Kamat: Great. Thank you so much, Justin. That was a great summary of our findings and the paper. Let me ask you a couple of questions. First off., were you surprised by what you found in this analysis?
Justin Matulay: I was not surprised that low-risk was being surveyed more intensely. However, I was surprised by the degree to which it was being over-managed, so to speak. The amount of cystoscopy and upper tract imaging that was being used at very frequent intervals for a disease that, when we look at the data, we don't really have any data to support that. I think that there is a decent amount of retrospective data to support deescalating the followup. For instance, that these solitary low-grade tumors that have very low recurrence rates of not even one per year, those patients don't necessarily need to have their every six-month or their annual cystos, that those patients can be stretched out to either longer intervals, or even just managed expectantly. And we don't have any indication that that would be oncologically dangerous to them.
Ashish Kamat: Yeah, no. Because if you look at the AUA guidelines, it's only around 2016 that they started recommending we could space out the interval to nine months, or 12 months, pretty early. Whereas in Europe, this was popularized back in the early 1990s. It certainly might just be a reflection of the more recent iteration of the guidelines. But do you think that it's also in some ways cultural, from the sense of a patient perspective? Or maybe the patients are asking for more intensive surveillance? What's your sense there?
Justin Matulay: I think yes. I think it also shows an unwillingness to potentially miss a tumor, and have a patient potentially even become litigious over missing a tumor. Even though again, that we don't necessarily see any kind of longterm effect that would be detrimental to the patient, it is definitely a cultural phenomenon in the US that people who have been diagnosed with cancer, low-grade papillary bladder cancer, even at its indolent course, people have been told that they have cancer. They want to make sure that their cancer doesn't progress, doesn't become life-threatening. I think that it would be only through a real cultural shift, and starting with the experts in the field pushing towards less intensive monitoring, and giving the impression that maybe even comparing it to something like Gleason 6 prostate cancer, which is starting to have a much better acceptance of active surveillance. Maybe if we compare it to something like that, in terms of the longterm outcomes being so favorable, maybe we can change the tide.
Ashish Kamat: Justin, you've also done a good amount of work with the International Bladder Cancer Group. You published recently on the management of low-risk bladder cancer patients. Could you touch upon that just briefly, and how that would tie into your findings here?
Justin Matulay: Sure. The International Bladder Cancer Group identified low risk nonmuscle-invasive bladder cancer as a particular entity within urologic oncology within bladder cancer that needed a closer look, that was perhaps being over-managed. Through extensive literature review, systematic literature review, and expert collaboration, we were able to come to a consensus regarding recommendations for the diagnosis, the management, and the longterm surveillance, of low grade or low-risk, bladder cancer.
Essentially, the final recommendations were, that not only should you be spacing out your cystoscopies, not only should you be avoiding the use of urinary cytology, really beyond that initial diagnostic period, but you could even consider stopping cystoscopy altogether after a certain period of time, after perhaps five years or so. And that you can manage somebody based on the return of symptoms, rather than chasing after finding that one small papillary recurrence, that poses almost no risk of progression.
Then along with that as well, is avoiding the use of intravesical therapies for these low-risk bladder tumors, beyond a single postoperative dose of intravesical chemotherapy, avoiding the use of the more intensive intravesical regimens, and specifically BCG. That this should never be used, especially given the annual shortages that we tend to face.
Ashish Kamat: Lastly, we've talked about this before, how do you plan to use the data that you've gathered in the survey, and translate it into clinically effective or clinical effectiveness research projects?
Justin Matulay: I think that this really has identified an area of need. That there is a need, and there's an area that we can improve our, again, not just our cost savings as urologists, in a very expensive to manage bladder cancer, or type of cancer, in low-risk bladder cancer, but also a way that we could potentially improve the patient experience by changing the attitudes towards this. I think that using this data to say we're starting at a point of such intensive annual invasive procedures and imaging tests, let's see what are the patient attitudes towards this? Maybe let's see what is the feasibility of doing some kind of even prospective study to measure the outcomes related to easing the intensity of surveillance, and the use of adjunctive surveillance techniques?
Ashish Kamat: Thanks. So in closing, I just want to say that it's been wonderful to have you here in our program for the last two years. For me personally, it's been a great experience to serve as your mentor, and I have no doubt that you are going to excel, and do great things in your future endeavors. So congratulations.
Justin Matulay: Thank you very much. Thank you very much, Dr. Kamat. I really enjoyed my time working under you and working at MD Anderson. So I'll always look back fondly.